Transcript Ethical significance of patient preferences

Chapter Four
Preferences of Patients
the ethical and legal nucleus of a
patient-physician relationship
patient preferences
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the choices that persons make when they
are faced with decisions about health and
medical treatment, should be made by
patients based on the information
provided by a physician, as well as by the
patients’ own experience, beliefs, and
values.
Clinical significance of
patient preferences
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Patient preferences are essential to
good clinical care, because the
patient’s cooperation and satisfaction
reflect the degree to which medical
intervention fulfills the patient’s
choices, values, and needs.
(hypertension, non-insulin-dependent
diabetes mellitus, peptic ulcer disease, and
rheumatoid arthritis.)
participatory decision-making style
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Research has shown that patients
with chronic disease enjoy better
health outcomes when they ask
questions, express opinions, and
make their preferences known, and
when their physicians have a
“participatory” rather than a
“controlling” decision- making style.
patient-centered medicine
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refers to the physicians and
patients share authority and
responsibility in order to build
therapeutic alliances.
Ethical significance of patient
preferences: Autonomy
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The recognition of patient preferences
respects the value of personal
autonomy in medical care.
It is morally permissible to constrain a
person’s freely chosen actions only
when that person’s preferences and
actions seriously infringe on the rights
and welfare of others.
legal significance of patient
preferences: self-determination
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the legal right of patients to control
what is done to their own bodies.
Failure to obtain adequate informed
consent may open a physician to charge
of negligence.
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Finally, apart from clinical skill and
carefulness, a respect for patient
preferences, good communication, and
a participatory style of dealing with
patients appear to be the most effective
protection that physicians have against
malpractice lawsuits.
psychological significance of
patient preferences: control
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The ability to express preferences and have
others respect them is crucial to a sense of
personal worth.
When patient preferences are ignored or
devalued, patients are likely to distrust and
perhaps disregard physicians’ recommendations.
When patients are overtly covertly
uncooperative, the effectiveness of therapy is
threatened.
Paternalism
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Refers to the actions and attitudes of
some authority figure who judges that
he or she knows best what is good for
another person who has the capacity
and knowledge to judge for himself or
herself, thus overriding or ignoring
that patient’s preferences.
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In ethical terms, paternalism represents
the opinion that beneficence is higher
value than autonomy.
Consent is not required when:
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(1) The patient is unconscious and
requires emergency treatment.
(2) Testing for certain infectious disease:
these include the “notifiable” disease of
cholera, plague, relapsing fever, smallpox
and typhus
(3) The patient is incapable of giving
consent, (mental disability or a young
child).
Informed Consent
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The physician makes a diagnosis and
recommends treatment, then explains these to
the patient, giving the reasons for the
recommended treatment, the opinion of
alternative treatment, and the benefits and risks
of all options. The patient understands the
information, assesses the treatment choices,
and expresses a preference for one of the
options proposed by the physician.
4.1 Informed consent
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Requires a dialogue between physician
and patient leading to agreement about
the course of medical care.
4.1.1 Informed consent:
standards of disclosure
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What a reasonable and prudent physician
would tell a patient？
What information reasonable patients
need to know to make rational decisions?
Is the information provided specifically
tailored to a particular patient’s need for
information and understanding?
4.1.2 Scope of disclosure
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the patient’s current medical status,
including the likely course if no treatment
is provided;
the interventions that might improve
prognosis, including a description and
the risks and benefits of those
procedures, and some estimation of
probabilities and uncertainties associated
with the interventions;
4.1.2 Scope of disclosure
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a professional opinion about
alternative open to the patient;
a recommendation that is based
on the physician’s best clinical
judgment.
4.1.3 Comprehension
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Explanation
Questions
Written instructions or printed materials
Video or computer programs
Educational programs
4.1.5 Difficulties with
informed consent
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an undesirable and perhaps
impossible task
shared decision making
limitations of physician
communication and patient
comprehension
4.2 Decisional capacity
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4.2.1The concept of decisional
capacity
the ability to understand relevant
information, to appreciate the medical
situation and its possible consequences,
to communicate a choice, and to
engage in rational deliberation about
one’s own values in relation to the
physician’s recommendations about
treatment options.
4.2.2 Determining decisional
capacity
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to engage the patient in conversation,
to observe the patient’s behavior,
to talk with third parties---family, or
friends, or staff.
4.2.2 Determining
decisional capacity
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too quickly agree to a physician’s
recommendations may not really
understand what is being
proposed
appropriate surrogate decision
maker assumes authority
4.2.3 Evaluating decisional capacity in
relation to the need for intervention
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When patients reject recommended
treatment, clinicians may suspect that
the patients’ choice may be harmful to
their health and welfare and assume
that persons ordinarily do not act
contrary to their best interests.
(antibiotics for bacterial meningitis )
4.4 Truthful communication
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Communications between
physicians and patients should be
truthful;
that is, statement should be in
accord with facts.
4.4 Truthful communication
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Does the patient really want to know
the truth?
What if the truth, once known, causes
harm?
Might not deception help by providing
hope?
4.4 Truthful communication
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There is a strong moral duty to tell the
truth that is not easily overridden by
speculative, possible harms of knowing
truth.
Suspicion on the part of the physician
that truthful disclosure would harmful to
the patient may be founded on little or no
evidence.
4.4 Truthful communication
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Patients have a need for the truth if
they are to make rational decisions
about actions and plans for life.
Concealment of the truth is likely to
undermine the patient-physician
relationship. In case of serious illness, it
is particularly important that this
relationship be strong.
4.4 Truthful
communication
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Toleration of concealment by the
profession may undermine the trust that
the public should have in the profession.
Recent studies have shown that most
patients with diagnoses of serious illness
wish to know the diagnosis.
4.4.2 Disclosure of
medical error
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Case The patient is treated by breast surgery.
She develops persistent swelling and drainage of
the breast and a fever consistent with a breast
abscess. She is returned to the operating room
for exploration of the operative site. The surgeon
discovers that a sponge had been left in the
surgical wound. The sponge is removed, and the
abscess is treated. The patient recovers and is
discharged. Should the physician inform the
patient that a mistake had been made?
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Any inclination to hide medical mistake
must be discouraged. Organizations
also should institute strong system to
prevent errors that might be due to
system faults.
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A climate of disclosure and honesty is
necessary to maintain patient
confidence and trust in the relationship
with their physicians and with the
health care institutions.
If the context of confidence and
honesty is sustained, legal claims most
probably is misplaced.
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Errors that are truly harmless, without any
adverse effects for the patient, must be
reported within the system for control
purpose.
Although it is not obligatory to disclose
harmless error, it is advisable to do so to
sustain the climate of honesty in the
relationship between the patient and
physician.
Example 1
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Tom Johnson: 50 Yr old male, 20 year history
of intermittent low back pain without
radiation to the legs, muscle weakness or
sensory symptoms. His relapses resolve with
rest and OTC analgesics. During a visit, he
reports that he had x-rays of the spine years
ago that were normal. He requests MRI
studies to find out what is really going on.
Example 2
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Ms Dickens, has severe hypertension and
COPD. She has done well on inhaled steroids
and has required little attention from her
physician for her COPD. Her hypertension is
difficult to manage. In frustration, her doctor
adds a long-acting beta blocker to her
regimen, not thinking about her bronchospasm. Three days later, she experiences
severe shortness of breath that does not
respond to her inhalers. Her son asks “What
brought this on?” The doctor feels bad about
his error, but feels that little is to be gained by
admitting it.
Example 3
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Dr. Yu looks at the schedule and groans.
Mr. Erlich is one of the first patients
scheduled. Mr. Erlich routinely takes up
so much time asking questions and
raising concerns, that Dr. Yu runs late
for the rest of the day and has to rush
through seeing some of the other
patients.
Fundamental Principles
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Primacy of patient welfare – altruism
Patient autonomy
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Honesty
Empower to make informed decisions
Patient’s decisions paramount less conflict with
principles
Social justice
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Fair distribution of resources
End discrimination
Responsibilities
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Competence
Honesty with patients
Patient confidentiality
Relationships with patients
Improve quality of care
Improve access to care